A 35 year old HIV positive patient from Hong Kong presented with a fever, cough and a skin rash in association with a lung mass, all of which were due to disseminated Penicillium marneffeiinfection. He made a good response to antifungal therapy. The lung mass is a previously undescribed pulmonary manifestation of disseminated Penicillium marneffei infection. Infections with this fungus should be suspected in any patient with HIV and respiratory symptoms who has visited southeast Asia.
- Penicillium marneffei
- southeast Asia
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Penicillium marneffei is a dimorphic fungus endemic in southeast Asia which recently has become an important opportunistic infection in HIV positive individuals with very low CD4 lymphocyte counts in North Thailand.1 Some of the features of disseminated P marneffei infection such as fever and cough are non-specific and common to many opportunistic HIV infections, but cutaneous lesions can help to distinguish this infection from others. Pulmonary involvement is not uncommon but is usually subclinical. We describe the case of an HIV positive patient who presented with a rash and a right upper lobe mass which was due toP marneffei infection, a previously undescribed pulmonary manifestation of this fungus.
A 35 year old Chinese man presented in 1995 with a three month history of increasing shortness of breath, productive cough, and fever in association with skin lesions on his limbs and trunk. He was born in Hong Kong and moved to England at the age of 12 years. He had visited Hong Kong and southern China for one month in 1992 and for two months in 1993 but had not otherwise left the United Kingdom. He had been an intravenous drug user in the past and was first diagnosed as being HIV positive in 1992. He had been well until this presentation except for an episode of Pneumocystis carinii pneumonia (PCP) in 1993, his only AIDS defining illness to date. He was taking dapsone for PCP prophylaxis and smoked 10 cigarettes a day.
On examination he was febrile (38.4°C) and had generalised lymphadenopathy. There were several well circumscribed dark red papules on his skin which were crusted at the edges, characteristic of lesions seen in P marneffei infection (fig 1). Examination of his respiratory, cardiovascular, and gastrointestinal systems was unremarkable. Oxygen saturation on pulse oximetry was 88% on air.
Initial investigations gave the following results: haemoglobin, 10.8 g/dl; white cell count, 4.5 × 109/l (lymphocytes 0.73, neutrophils 3.19, monocytes 0.23, eosinophils 0.36); platelets, 109 × 109/l; erythrocyte sedimentation rate, 75 mm/h; C reactive protein, 16 mg/l; CD4 lymphocyte count, 0.02 × 109/l (normal 0.4–1.0 × 109/l). Routine biochemistry was normal. His chest radiograph showed a dense opacity in the right upper lobe with diffuse generalised bilateral air space disease (fig 2). A CT scan of the chest showed multiple medium sized nodules throughout both lung fields and a segmental soft tissue mass in the right upper lobe which abutted the pleural surface and measured 5 × 7.5 cm. Sputum microscopy and culture were negative for bacteria, mycobacteria, and fungi. Fibreoptic bronchoscopy revealed a tumour-like lesion on the posterior tracheal wall and a distorted right middle lobe with no endobronchial lesion visible. Bronchial lavage fluid was negative on microscopy and culture but biopsy specimens of the tracheal lesion, skin, and right upper lobe lesion had an identical histological appearance showing a mononuclear cell infiltrate with fungal yeast forms within macrophages. P marneffei was isolated from all biopsy samples. Blood cultures were negative.
The patient was started on intravenous amphotericin but, because of side effects, his treatment was changed after 48 hours to high dose oral itraconazole, 200 mg twice daily. His skin lesions began to regress and his chest symptoms resolved within a week of starting treatment. Six months later his skin was clear and the chest radiograph was normal except for a small residual right upper lobe opacity. He remained well on itraconazole until developing cytomegalovirus (CMV) retinitis 18 months later, subsequently dying of CMV encephalopathy.
In endemic areas disseminated P marneffei infection is recognised as an increasing problem in patients with HIV infection. It is now the third most common opportunistic infection in the HIV population in northern Thailand after extrapulmonary tuberculosis and cryptococcal meningitis.2 An important clue to the diagnosis is a characteristic papular skin rash, often with central umbilication or necrosis, resembling giant molluscum contagiosum. In a recent series of 86 patients co-infected with HIV and P marneffei 71% had these characteristic skin lesions.2 Pulmonary involvement has been described as being diffuse or focal with either an alveolar or reticulonodular pattern of involvement. A single case of a pleural effusion due toP marneffei has also been reported. Ours is the first description of a solid lung mass and an endotracheal lesion in this condition.
The patient was clinically suspected of having disseminated P marneffei infection on the basis of his skin lesions and travel history, but the extent of his pulmonary disease prompted a search for other pathogens such as Mycobacterium tuberculosis orCryptococcus neoformans. Extensive investigation revealedP marneffei as the sole cause of his presenting symptoms and signs. Infection with this fungus should be suspected in HIV positive patients presenting with fever and a papular rash who have visited southeast Asia.3 We have shown that patients may also present with a mass lesion in the lung and that prompt recognition and institution of treatment can lead to an almost complete resolution of the disease.
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